Adult Registration Form printable pdf download

Office Use Only

Date Received______________

New______

Returning______

Class______________________

Adult Registration Form

Registration Forms are required for each individual student. Please print legibly.

Student Name____________________________ _________________________Class Registering For_________________________________

Phone checked Regularly_____________________________E-Mail_____________________________________________________________

Address______________________________________________________________City________________________State____Zip_________

Emergency Contact

(in case of injury)

Name__________________________________________________________________________________Phone #_______________________

Classical Ballet Academy will NOT release any of the above information to anyone outside of the studio without your permission.

Liability Waiver/Release

Must be signed for student to participate in classes.

Please read carefully before signing.

I _______________________________________________, the enrolled participant and/or the parent/guardian of the participant

agree and understand that dance/fitness training is a potentially hazardous activity. I recognize that there are risks inherent in dance

training including, but not limited to, serious physical injury. The participant hereby agrees to participate in activities of the Classical

Ballet Theatre of Northern Virginia and hereby agrees to indemnify and hold harmless Classical Ballet Theatre, its instructors,

officers, directors, agents and employees against any liability resulting from any injury that may occur to the participant while

participating in activities of the Classical Ballet Theatre of Northern Virginia. The participant also agrees to indemnify Classical Ballet

Theatre for any damages incurred arising from any claims, demand, action or course of action by the participant.

The participant authorizes any representative of Classical Ballet Theatre of Northern Virginia to have the participant treated in any

medical emergency during their participation in activities of the Classical Ballet Theatre. Further, the participant and/or

parent/guardian agrees to pay all costs associated with medical care and transportation for the participant.

Any special medical/health problems or needs of which the staff should be aware are outlined in an attached form.

I HAVE CAREFULLY READ THE ABOVE LIABILITY RELEASE AND SIGN IT WITH FULL KNOWLEDGE OF ITS CONTENT AND

SIGNIFICANCE. ADDITIONALLY, I HAVE READ AND AGREE TO ABIDE BY ALL STUDIO POLICIES AND PROCEDURES.

____________________________________________________________________

Student’s Name (please print)

____________________________________________________________________

Signed

Date

____________________________________________________________________

Parent/Guardian (if participant is under 18) (please print)

____________________________________________________________________

Signed

Date

Classical Ballet Theatre

320 Victory Drive, Herndon, VA 20170

703-471-0750

Adult Registration Form